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Volkan Etus and Savas Ceylan

✓The authors of this paper describe two patients with achondroplasia in whom triventricular hydrocephalus has been successfully treated using endoscopic third ventriculostomy (ETV).

The authors performed ETVs in two children with achondroplasia involving a moderate macrocranium and enlarged lateral and third ventricles with intermittent clinical evidence of increased intracranial pressure. The endoscopic procedure revealed a significant deformation of the floor of the third ventricle in both patients caused by longstanding hydrocephalus. Because of the anatomical variations such as empty sella and the persistence of the infundibular recess, the ETV procedure became technically demanding. The standard ventriculostomy on the tuber cinereum was not possible. Ventriculostomies were performed on the part of the third ventricular floor that was hanging ventral to the pons.

Both patients became symptom free postoperatively, and phase-contrast cine magnetic resonance (MR) imaging studies confirmed the patency and effectivity of the ventriculostomy sites. The authors suggest that ETVs may constitute an alternative for ventriculoperitoneal shunt therapy as the treatment of choice for patients with achondroplasia who have triventricular hydrocephalus and clinical symptoms. Attention should be paid to the shape of the floor of the third ventricle, however, especially in cases of longstanding hydrocephalus. An association of the empty sella or the persistence of the infundibular recess must be carefully evaluated using MR imaging studies before attempting ETVs in such patients.

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Soner Duru, Süreyya Ceylan and Savaş Ceylan

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Savas Ceylan, Kenan Koc and Ihsan Anik

Object

In this report, the authors describe their experience with surgical access to the cavernous sinus via a fully transnasal endoscopic approach in 20 cases. Clinical and endocrinological follow-up are discussed.

Methods

The authors used an endoscopic transsphenoidal approach in 192 patients with pituitary adenomas between September 1997 and January 2008, adding a cavernous sinus approach in 20 patients with invasive tumors during the last 5 years of this period. Parasellar extension of the tumor was measured according to the Knosp Scale. Radical tumor removal was achieved in 13 (65%) of 20 patients, and subtotal removal in 7 (35%). The authors used recently defined cavernous sinus approaches in the first 14 cases, including the paraseptal approach in 6, middle turbinectomy in 7, and contralateral middle turbinectomy in 1 case. Combined approaches rather than defined standard cavernous sinus approaches were used in 4 cases and an extended approach in 2.

Results

The tumors included nonsecretory adenomas in 5 cases (25%), growth hormone–secreting adenomas in 7 (35%), prolactin-secreting adenomas in 4 (20%), and adrenocorticotropic hormone–secreting adenomas in 4 cases (20%). Normal growth hormone and insulin-like growth factor 1 levels were achieved in 4 patients (57%) with growth hormone adenomas, and remission criteria were obtained in 3 patients with prolactinomas and 3 patients with adrenocorticotropic hormone–secreting adenomas.

Conclusions

Compared with transcranial and microscopic transsphenoidal surgery, endoscopic transsphenoidal surgery offers a wide exposure for cavernous sinus medial wall adenomas that enables removal of the adenoma from the medial cavernous sinus wall. Because of the necessity for multidisciplinary treatment to achieve satisfactory results, Gamma Knife surgery and medical therapy should be supplementary treatment options after endoscopic transsphenoidal surgery.

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Volkan Etus, Ozlem Kurtkaya, Kenan Koc, Ercument Ciftci, Aydin Sav and Savas Ceylan